15.2 Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) refer to traumatic events or circumstances during childhood—including neglect, abuse, witnessing violence, or having a family member with substance abuse, mental illness, divorce, or imprisonment. In the late 1990s, the landmark Adverse Childhood Experiences Study examined over 17,000 participants to assess the long-term impact of these experiences on adult health and behavior.The study revealed that as the number of ACEs increased, children were more likely to develop behavioral problems and engage in risky behaviors during adolescence, such as substance  abuse and unprotected sexual activity that could lead to pregnancy. These early-life challenges often set the stage for further health complications later in life. In adulthood, individuals with multiple ACEs were more likely to struggle with substance abuse and suffer from chronic illnesses—including alcoholism, chronic pulmonary disease, depression, and liver disease. Remarkably, those with the highest levels of ACEs had a life expectancy that was, on average, 20 years shorter than that of individuals with few or no ACEs^[1]See Figure 15.1^[2] for an infographic of ACEs.

A systematic review and meta analysis in 2024 across demographic characteristics and contexts found that ACEs in children younger than 18 years of age was common, with prevalence of 42% of children having no ACEs, 22% having 1 ACE, 13% having 2 ACEs, 8% having 3 ACEs, and 15% having 4 or more ACEs. The prevalence of 4 or more ACEs was higher among children in residential care, with a history of juvenile offending, and in Indigenous peoples.^[4]

For some individuals, traumatic experiences during childhood can cause long term psychological and physical problems due to its impact on the child’s developing brain. Various biopsychosocial and cultural factors influence an both immediate and long-term responses to trauma. In most cases, regardless of severity, individuals display resilience—the capacity to overcome adversity and face challenges with determination. This resilience involves mobilizing available resources to navigate hardships and mitigate the impact of adverse events.^[5]

While being sensitive to a client’s history of trauma and helping support them throughout their life is important, we know that these traumatic experiences are often preventable.  Nurses throughout our communities can advocate for improvements, to help promote building positive social relationships and reduce the exposure to violence in children. The Centers for Disease Control and Prevention (CDC) created a resource titled Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence. This resource contains these six strategies:

• Strengthen economic supports to families
• Promote
• social norms that protect against violence and adversity
• Ensure a strong start for children
• Teach skills
• Connect youth to caring adults and activities
• Intervene to lessen immediate and long-term harms

Risk Factors, Protective Factors, and Prevention Strategies

By bringing attention to the powerful impact that negative childhood experiences have on future health and functioning, the ACE study demonstrates the importance of designing early intervention programs that target abuse, neglect, and violence.^[7] Nurses can help prevent ACEs by educating parents, communities, and policymakers about how to help families provide safe and stable environments for children.

Many factors contribute to ACEs, including personal traits and experiences, parents, the family environment, and the community itself. ACEs can have lasting negative effects on health and well-being, but these harms can be preventable. To prevent ACEs and protect children from neglect, abuse, and violence, nurses are involved in addressing these risk factors and protective factors with prevention strategies.^[8]

Appropriately addressing traumatic experiences and promoting resilience are important parts of effective mental health care and integral for the healing and recovery process.^[9]

Risk Factors

Risk factors are conditions that increase the likelihood of experiencing ACEs. There are individual, family, and community risk factors for ACEs.

Individual and Family Risk Factors

Individual and family risk factors include the following^[10]:

Individual:

• Children and adolescents who don’t feel close to their parents/caregivers or feel they can’t talk to them about their feelings
• Youth who start dating or engaging in sexual activity at an early age
• Children and youth with few or no friends or with friends who engage in aggressive or delinquent behavior

Families experiencing:

• Caregiving challenges related to children with special needs (e.g., disabilities, mental health issues, chronic illnesses)
• High levels of stress from parenting or economic issues
• Isolation from extended family, friends, or neighbors

Families with caregivers who:

• Have a limited understanding of children’s needs or development
• Were abused or neglected as children
• Are young or single parents

Families with:

• Low income or low levels of adult education
• High conflict and negative communication styles
• Attitudes accepting of or justifying violence or aggression
• Inconsistent discipline, corporal punishment, and/or low parental supervision

Community Risk Factors

Communities with^[11]:

• High rates of violence and crime
• Limited educational and economic opportunities
• High rates of poverty, unemployment rates, and food insecurity
• Easy access to drugs and alcohol
• Low community involvement among residents
• Few community activities for youth
• Unstable housing where residents move frequently

Protective Factors

Protective factors help reduce the likelihood of ACEs and support resilience.

Individual and Family Protective Factors

Individual and family protective factors against ACEs include the following^[12]:

Children who:

• Have positive friendships and peer networks
• Experience academic success
• Have caring adults outside the family as mentors/role models

Families where caregivers:

• Can meet children’s basic needs (food, shelter, health services)
• Create a stable, supportive home with nurturing relationships
• Engage in positive parenting with consistent rules and supervision
• Help children work through problems and resolve conflicts peacefully
• Encourage the importance of school and academic success
• Have strong social support networks and positive relationships

Families with:

• Caregivers who have higher education or steady employment
• Fun, positive activities that strengthen family bonds

Community Protective Factors

Communities can intervene to lessen the harms from ACEs and prevent future risks.

Communities where^[13],[14]:

• Families have access to education and support regarding positive parenting
• Families have access to economic and financial help
• Families have access to medical care and mental health services
• Individuals and families have access to safe, stable housing
• Families have access to nurturing and safe child care
• Families have access to high-quality preschool programs
• Families have access to safe, engaging after-school programs and activities
• Adults have work opportunities with family-friendly policies
• There are strong partnerships among the community and business, health care, government, and other sectors
• Residents feel connected to each other and are involved in the community
• Violence is not tolerated or accepted in the community
• Positive parenting strategies are social norms in the community